Written by Kent Holtorf, MD

Obesity has become a major health epidemic and has dramatically increased over the last decade. Studies show that approximately one-third of the U.S. population is classified as obese and over two-thirds are significantly overweight. While the cause is multifactorial, studies are clear that almost all overweight individuals have metabolic and endocrinological dysfunction that is causing or contributing to their inability to lose weight.

Losing weight with hypothyroidism can be a difficult task. Therefore, thyroid patients need to know more about factors that are likely at work contributing to weight loss challenges.

1. Get Reverse T3 Checked For Low Thyroid Problem

Some physicians believe treatment of hypothyroidism is simple. Give the patient a prescription for T4, in the form of Synthroid or generic Levothyroxine, and everything will be fine. But sometimes, what might be the perfect treatment for one patient will actually make another patient much sicker. For patients with thyroid hormone conversion problems, treatment with T3 can be very beneficial.

To properly treat hypothyroidism, you must first know your Ts. Thyroxine, or T4, is the thyroid “storage hormone.” Triodothyronine, or T3, is the “energy hormone.” For the body to use T4, it must first convert it to the active hormone T3, giving energy to every cell in the body.

Another critical thyroid hormone is reverse T3 (RT3). Reverse T3 is the body’s “emergency brake.” Many endocrinologists believe that Reverse T3 is simply an inactive metabolite with no physiologic effect on the body. They couldn’t be more wrong.

In some patients, instead of properly converting T4 to T3, the body converts too much T4 to reverse T3, effectively shutting down the body. These patients often experience debilitating fatigue and weight gain, and continue to get worse in spite of taking T4 thyroid hormone medication.

Thyroid hormone conversion problems can be caused by a number of common issues including significant stress, depression, a history of dieting, insulin resistance, obesity, diabetes, chronic fatigue syndrome, fibromyalgia, autoimmune diseases, chronic inflammation, chronic infections, PMS, iron deficiency, and many more. Any one of these issues could cause a patient to have too much RT3 or an improper T3/RT3 ratio.

Now imagine that a patient with a thyroid hormone conversion problem – i.e., too much RT3 – is seeing a doctor who “doesn’t believe in RT3.” It’s a recipe for disaster. The more T4 the doctor gives the patient to improve hypothyroid symptoms, the worse the patient will feel, because too much of that T4 is being converted into more RT3. And all the while, the patient’s TSH test appears to be “normal.” Although the patient isn’t getting better, the doctor refuses to order lab tests to check for RT3, and tells the patient that she’s fine, that her labs are in range, that she must exercise more and eat less, or that it’s all in her head.

Regardless of whether or not your TSH is “in range,” if you have too much RT3, you are hypothyroid. Treating a patient with RT3 issues requires a deep understanding of the subtle nuances and complexities of thyroid disorders, as well as a willingness to treat based on a combination of factors, including patient symptoms, rather than simply relying on standard thyroid tests like TSH and T4. It is critical to do comprehensive testing, including a full thyroid panel for TSH, free T4, free T3, RT3 and thyroid antibodies. In addition, a sex hormone binding globulin (SHBG) test can help determine the cellular level of T3. A goal of proper thyroid replacement is to have an optimal metabolism, so this should be checked before and during treatment. Reflex response tests should also be done, because studies show that the speed of the relaxation phase of a reflex is a better test for hypothyroidism than the TSH. Thorough testing and examination to determine what is causing the conversion issues are key, and steps should be taken to correct any related problems.

It’s also important to look beyond the standard T4 treatment. Patients with RT3 issues often see improvement with preparations containing combinations of T4 and T3, and especially with straight time-released T3. By providing the body with some or all of the T3 that it needs, the thyroid will produce less T4. With less T4 to convert to RT3, the patient’s system can slowly regain proper thyroid hormone balance. Conversely, continuing to give T4 preparations or refusing to treat RT3 issues means the patient will become increasingly hypothyroid.

2. Manage Your Metabolic Set Point

Does it seem that your scale always seems to land on the same number, no matter how hard you diet, how much you cut calories, or how hard you exercise? If so, you may be struggling with a malfunctioning “set point.”

The “set point” is the brain’s target weight for a person’s body. Just as the body works to maintain a fairly standard temperature of 98.6 degrees Fahrenheit, it also works to maintain a body weight that is physiologically comfortable. The set point is maintained by the hypothalamus, and is often genetically influenced. However, a number of things can cause the set point to change, moving a person’s normal weight to a higher number on the scale, and sabotaging weight loss efforts.

One of the more common causes of set point malfunction is aggressive or yo-yo dieting. Calorie restrictive diets can actually slow thyroid function, resulting in a slower metabolism. Illnesses such as chronic fatigue or fibromyalgia can also cause the set point to malfunction. Some medications can cause the set point to increase, including common antidepressants such as Paxil, Celexa, Zoloft and Lexapro, anti-convulsant medications, blood pressure medications, anti-seizure or pain medications such as Neurontin or Lyrica, birth control pills, synthetic hormone replacement, and diabetic medications that stimulate insulin secretion, such as glyburide and Amaryll.

The set point can also increase as a natural effect of aging. However, this cause is typically related to hormone decline, which can be successfully treated.

Fortunately, there are solutions that can help to lower the body’s set point to a more acceptable number. These include thyroid hormone optimization, consistency in diet and exercise levels, and aggressive management of conditions such as chronic fatigue, fibromyalgia, chronic infections, and chronic inflammation.

If added support is needed, there are now medications that can be used to lower the set point and increase weight loss success. Naltrexone, a drug typically used in high doses as a treatment for narcotic opioid overdose and to help patients detox from narcotic addiction, is showing success in decreasing the body’s set point when used as much lower doses. Referred to as low-dose naltrexone, this drug is now widely used as an effective immune modulator, and is helpful for managing autoimmune conditions such as Hashimoto’s disease, Grave’s disease, and Lupus. At a dose slightly higher than “low-dose,” Naltrexone has been shown to reduce the body’s set point, working at the level of the hypothalamus, bringing about significant weight loss.

The success of naltrexone for weight loss is greatly enhanced when combined with the common antidepressant, Wellbutrin. Patients lose an average of a half pound per week, and experience reduced appetite and cravings. In one clinical study, the LDN plus Wellbutrin combination protocol was shown to result in significant weight loss at more than twice the rate of placebo, with an average weight loss of more than 17 pounds.

3. Decrease Leptin Resistance

Leptin is an important hormone, which stimulates metabolism, reduces appetite, and signals the body to burn fat. It’s known as the “starvation hormone” because it notifies your brain when you have enough food in your stomach and your energy levels are sufficient. Leptin is secreted primarily from fat cells. It usually correlates to fat mass – the more fat you have, the more leptin you produce. Women tend to have higher leptin levels than men thanks to their higher body fat percentage. Studies suggest leptin increases during the luteal phase of the menstrual cycle due to the effects of estradiol and progesterone.

The body secretes leptin as weight is gained to signal the brain (specifically the hypothalamus) that there is adequate energy (fat) storage. New research has found that this leptin signaling is dysfunctional in the majority of people who have difficultly losing weight. Studies show that the majority of overweight individuals who are having difficulty losing weight have a leptin resistance, where the brain receptors become desensitized or resistant to leptin when a surge of leptin is prolonged and are no longer able to respond to the signal. Despite the excess of leptin the person with leptin resistance actually suffers from symptoms of low levels of the hormone. The overweight person may be feeling hungry more often and store fat too readily. Instead of feeling satisfied, his/her brain instructs the body that it needs more food. It’s a vicious cycle.

There are many factors that can negatively impact leptin levels including: fructose and simple carbs consumption, overeating, lack of sleep and high stress, high insulin levels, exercising too much or too little, grain and lectin consumption.

Medications like Byetta and Symlin can contribute to a decrease in leptin resistance. These can have good results if given in conjunction with other metabolic treatments and following a healthy diet and lifestyle. In a randomized, double-blind placebo controlled, cross-over trial, it was found that short-term use (less than 4 months) of the leptin sensitizing medication, resulted in significant weight loss in 65% of individuals.

4. Resolve Insulin Resistance

When suffering from hypothyroidism, everything in your system slows down right down to your cells. The body’s ability to process carbohydrates slows down too, as does your cell’s ability to absorb blood sugar.

The brain, organs and muscles run off of glucose, the body’s preferred source of fuel. If your cells do not get the adequate amounts of glucose into them, you can’t produce energy to help run your body. Hormones are not produced optimally, brain function does not work properly and every system of your body suffers, including the ability to sleep, lose weight, immune and stress response, etc.

When cells become insulin resistant and the glucose can’t get in, it circulates round and round the bloodstream, damaging arterial walls and the brain. Because the body wants to normalize blood sugar levels as soon as possible, it converts the excess glucose into triglycerides to be stored as fat. This process demands so much energy that you become sleepy. Furthermore, insulin resistance decreases the body’s ability to use stored fat for energy.

The liver mediates between the activities of the insulin-releasing pancreas and the adrenal and thyroid glands, which are supposed to “tell” the liver to release glucose. If the adrenals and thyroid aren’t working properly on the “telling” end, or if the liver is sluggish, stressed out, or toxic, and not working on the “receiving” end, the system goes out of balance. Either way, the result is elevated excess insulin.

Any illness — including thyroid problems — also creates physical stress. And stress raises cortisol levels. Increased cortisol increases insulin levels. More insulin means increased chance of insulin resistance. Cortisol can also mobilize triglycerides from storage and relocate them to visceral fat cells (around the belly). Thus, getting rid of that belly is not easy for many people who don’t address all the underlying causes.

All these factors mean that insulin resistance is probably even more of a factor for overweight people with hypothyroidism than for the general population.

Today’s low-fat diets emphasize more and more high-glycemic carbohydrates like white flour baked goods, pasta, pizza, rice, potatoes, cereals, corn, desserts and sugary fat-free products, which can also trigger insulin resistance and obesity. Avoiding these types of carbohydrates is essential to a long term recovery.

People with insulin resistance feel tired most of the day and especially after meals, they are hungry all the time, have sweet cravings, which usually are not relieved after eating sweets, and might feel continuously thirsty.

Resolving insulin resistance needs a customized program. This involves the right diet, the right type of exercise and specific nutrients like berberine, chromium, magnesium and others.

5. Change Your Brain Chemistry

Hunger is intricately tied to your brain chemistry. When the hypothalamus senses you need energy, it issues the brain neurotransmitter neuropeptide Y (NPY) with the message “eat carbohydrates.” The surge of NPY is what you experience as “hunger.” This system can be dramatically altered by several factors, all of which can be present in chronic thyroid disease:

* Your body is under stress, which interferes with the neurotransmitter functions, and is known to reduce the release of serotonin.

Natural alternatives to boosting serotonin include aerobic exercise and the herbal treatment called St. John’s Wort (Hypericum perforatum).

6. Rule Out Hypothalamic Obesity Disorder

When the hypothalamus does not function properly it can affect your thyroid’s ability to take up T4 and convert it to T3. In this situation, hypothalamic obesity disorder can develop. With this condition, your nervous system continues to react as if you are starving, and you continue to gain weight.

Even with severe caloric restriction and high exercise, if you have hypothalamic obesity disorder, your metabolism is so impaired that it focuses on storing calories, rather than burning them, causing continued weight gain. In hypothalamic obesity disorder, there can also be an overproduction of insulin, which can further contribute to obesity.

7. Stay Hydrated

A surprisingly high number of people are dehydrated these days, without even knowing it. Consumption of coffee and alcohol dehydrate the body even more, as do processed foods which usually contain high amounts of salt. Insufficient electrolytes in the diet also affect hydration.

When your body becomes dehydrated cellular functions begin to slow down and proper hydration is necessary to keeping your metabolism going. In addition to helping the metabolism, proper water intake helps the body get rid of toxins. Drink half your body weight in ounces per day to ensure proper hydration, and a glass more if you drink coffee or alcohol.

8. Clean Up Your Diet

Acute or chronic dieting can result in a significant decrease in intracellular and circulating T3 levels by up to 50%, which significantly reduces basal metabolic rate (number of calories burned per day) by 15-40%. With chronic dieting, the thyroid levels and metabolism often do not return to normal levels; the body stays in starvation mode for years with significantly reduced metabolism despite the resumption of normal food intake, making it very difficult to lose or maintain lost weight.

Cleaning up your diet in an intelligent way is crucial. That means to avoid inflammatory foods from processed foods and ensure you are getting the right nutrients in to support your thyroid. White bread, pastries, pasta, packaged meals, artificial sweeteners, processed dairy and desserts all need to be avoided. Choose high quality, organic protein, fat and vegetables and limit your fruit intake to keep a healthy blood sugar level.

When you can’t keep your regular meals and/or need a snack, eat a small amount of protein every two to three hours. Going for long stretches without eating when you have dysglycemia, an abnormality in blood glucose levels, exacerbates your blood sugar issues, affecting other multiple metabolic processes in your body. Nuts, seeds, a boiled egg, cheese or meat are some examples of protein snacks.

9. Exercise, But Don’t Overdo It

Weight loss is very important to eliminate insulin resistance. The less you weigh, the less insulin resistant you will be. Even a daily brisk walk of 45 minutes to an hour can substantially reduce insulin levels. You can schedule this activity around the hours when you feel most rested. Exercising will help boost your metabolism, raise your resting metabolism, and burn calories.

But as it is with food, there is no one size fits all type of exercise for everyone. It is crucial to have your stress level assessed before you start doing more vigorous exercise. When we are exposed to any combination of stressors that elevate our stress hormone beyond the optimal, our repair hormones are suppressed.

It has been shown that women or men who perform more than moderate exercise, especially when associated with dieting, have reduced T4 to T3 conversion and increase reverse T3, counteracting many of the positive effects of exercise in women including weight loss. Consequently, T3 and reverse T3 levels should be evaluated in individuals who exercise and/or diet to better determine cellular thyroid levels, as TSH and T4 would not necessarily reflect tissue levels in such patients.

10. Get Enough Sleep

Lack of sleep, and especially chronic sleep deficit can have many negative reactions by affecting your hormones. It affects your ability to manufacture thyroid hormone properly and may impair T4 to T3 conversion, a crucial process for thyroid function. It lowers your production of growth hormone, which can help with weight loss and metabolism and interferes with the production and cycle of adrenal hormones. This can also lead to increased belly fat.

Sleep deprivation affects hormones that control appetite and in particular, cravings for simple carbohydrates and junk food. It also reduces levels of the hormone glucagon, which helps release fat from your cells. Less sleep means less fat is released. So these are plenty of good reasons to aim for the much-needed 8 hours of sleep, and an early enough bedtime.

About Dr. Kent Holtorf

Kent Holtorf, M.D. is the medical director of the Holtorf Medical Group with locations in Los Angeles, Foster City, Atlanta, and Philadelphia. He is also founder and director of the non-profit National Academy of Hypothyroidism (NAH), which is dedicated to dissemination of new information to doctors and patients on the diagnosis and treatment of hypothyroidism.

Dr. Holtorf has personally trained numerous physicians across the country in the use of bioidentical hormones, hypothyroidism, complex endocrine dysfunction, and innovative treatments of chronic fatigue syndrome, weight loss, fibromyalgia, and chronic infectious diseases, including Lyme disease.

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Dana Trentini B.S. summa cum laude, M.A., Ed.M., founded Hypothyroid Mom October 2012 in memory of the unborn baby she lost to hypothyroidism. This is for informational purposes only and should not be considered a substitute for consulting your physician regarding medical advice pertaining to your health. Hypothyroid Mom includes affiliate links including the Amazon Services LLC Associates Program. Connect with Dana on Google+

Comments

I was wondering if anyone had tried just LDN with SAM e instead of Wellbutrin. I”m not a huge fan of antidepressants. While originally I had been prescribed SAM e due to blood tests indicating myelin function. I have found it is a huge mood booster and it has all the same benefits for my body as an antidepressant without the side effects.
Also, I”m 48 years old and I have been working out since I was 17. This is not reflected in the look of my body (although it did keep my weight in check in my younger years between 20-35). I have a really hard time finding out where this fine line of exercise with “no to much, not too little” lies. I have heard that one should only do cardio about three times per week HITT training of about 20 minutes with 6 cycles of 30 second pushes all out. It’s really depressing to “work” so hard and yet not have that work pay off in terms of aesthetics. Does anyone have any experience with finding that balance of exercise?
Also, related to the t3 conversion issue, my doctor says that there is something called “Wilson’s Low Temperature” syndrome”. Has anyone gone through the protocol for that and did it work to get your thyroid at more optimal levels?

I had surgery for neuroendrocrine cancer in 2016 and still cant lose weight ,even though I had my ileum,appendix,14 lymph nodes and a right hemi.I dont hardly between meals,and have direeha almsot every day,sometime 7-9 times unless I take medicine for it.Seems like my stomach keeps getting bigger and bigger.My family doctor has never mentioned T3,but when I go back I will have him check evrything you mentioned.

Dear Dana and all my fellow suffering friends, I’m so glad to hear that I’m not alone in my search for good health and getting back to my normal self again. I too, I’m trying to understand the T3 and T4 thing, but I think if we read and re-read, we will understand it. And, we need to write down our questions and make our doctors answer them. That’s what I’m going to do. And, if they won’t give us the tests that we think we need, then we need to go to another doctor. We have to get ourselves well.

Synthroid doesn’t work for many. In fact it can make symptoms and Weight gain worse. Check your t3 levels. Anything lower than 3.0 should be treated with Cytomel. It’s a game changer. I feel like a normal person again.

It would be helpful if articles like this one would include a “print version”. I take articles with me in print form so I can make notes and read them at leisure/while waiting in line/etc. Too few things online are formatted this way, so I don’t have to print endless pages of ads and viewer’s comments.

Hi JC, I hear you about the print option and I’ve been thinking about including that feature at Hypothyroid Mom. In the meantime, try this while you are on the page of the article you would like to print. Select File then Print or type command P. This should open a printing window.

How do I get help? I have hypothyroid, sleep apnea, depression, anxiety, fibromyalgia, recently diagnosed type 2 diabetes, I’m so tired all the time, my family doc just keeps throwing medicine my way. I read these articles, blogs & research but I can’t focus or remember what I’m supposed to do. I’m a stay at home, home schooling mother of three & I’m failing my family. I have asked family doc to send me to endocrine doctor but he says my levels are good. At this point I’m focusing on low carb, low sugar diet; I just want my normal self back! Can anyone help, please?

Becky, I’m so sorry to read you are struggling. I remember that feeling too well but there is hope to be well even with hypothyroidism. Hope happened to me and that is why I created Hypothyroid Mom. The first two steps. One is to be sure you’ve had the right lab tests including thyroid antibodies for Hashimoto’s. Grab a copy of your lab results and check they’ve all been done or ask to have them done by your doctor:

And second is to read about the other thyroid medication options. If you are on a T4 only levothyroxine medication like Synthroid, that may be the issue. Here is information about the thyroid medication options you may not know about already:

Thank you so much , for such a well written document. I have been diagnosed with hypothyroidism for over 30 years and have never been able to understand what I understood when I read this document . I look forward to reading more of your written articles or books thank you so much M Johnson

I am hypothyroid and have the usual problems weight gain and can’t lose it however hard I try very depressing in itself and fatigue..have forgotten what it’s like to not feel tired.brain fog also is a big problem.but…I just can’t get my head round all these t4 t3 etc., maybe that’s the brain fog at work but I can’t understand at all how it works.i have been on thyroxine for years and years 125 mg.what should I be asking the doctor to test as obviously whatever the test shows and I am being treated for isn’t working.

Hi Pam, Iknow this is an old post but wondered how you’re getting on now? Your post resonated with me.. I have been diagnosed at start of this year… not sure how long it’s been really going on as thought it was menopause related symptoms…you still on 125mg? How you feeling? Any tips? I’m only 75mg ( up from 50mg) but don’t think it’s right yet… I exercise on average 5 x classes per week and eat healthy and little and cannot lose any of the excess weight that appeared (thought it was my early menopause), I’m 48 in few months,….. 😞any tips greatl6 received.

I’m not sure if the Hashimotos was directed at me, but thank you for the info. I haven’t been dx with anything yet. They said my tests were all over the board. I have the gut problem, which I just had upper and lower scopes done. He said everything looked good, but it isn’t. I cannot go out to eat unless there is a restroom right there. I have chronic diarrhea. I have the mental problem, anxiety all of the above. What bothers me the most is my body temp. And burning tongue. I am sick of being so hot all the time. I don’t know where to go or who to see. I need medical advice as to what I need to do or where I need to go. I even think I have narcolepsy. God help me. I can’t live like this. Right now my entire body is aching like I have to the flu. I hurt all the time. Please tell me what you would do if it were you. That’s what I need is a dr. to tell me what to do. Thanks so much again for the info. If.you can think of anything that.might help me, please email me.

Try giving up nightshades entirely for a month! That means no eating out either because a lot of food has paprika, which is a nightshade plant powder in it. A lot of sausages, bacon and other meat and fast food and things labeled “spices” and many spice mixes have paprika in them. Nightshade plants of all kinds can cause inflammation and flu type body ache.

Thank you so much, Hypothyroidmom.com, for educating me on this much-understood-by-Joe-Blogs illness! I’ve been hypothyroidic (if there is such a word!) for around 30 years. You have opened my eyes to a whole new way of approaching and dealing with my illness. You should be very proud of yourself for creating this incredibly informative website.